Y khoa, dược - Maintaining patient records

9Maintaining Patient Records9-29.1 Explain the purpose of compiling patient medical records.9.2 Describe the contents of patient record forms.9.3 Describe how to create and maintain a patient record.9.4 Identify and describe common approaches to documenting information in medical records. Learning Outcomes9-3Learning Outcomes (cont.)9.5 Discuss the need for neatness, timeliness, accuracy, and professional tone in patient records.9.6 Discuss tips for performing accurate transcription.9.7 Explain how to correct a medical record.9-4Learning Outcomes (cont.)9.8 Explain how to update a medical record.9.9 Identify when and how a medical record may be released.9.10 Discuss the advantages and disadvantages of the electronic medical record, also known as the electronic health record.9-5IntroductionMedical records document the evaluation and treatment of patientsCritical to patient careSectioned to describe various aspects of patient information and careLegal documentsMedical assistant has a major role in documenting in and maintaining patient records9-6Importance of Patient RecordsThe patient’s chartPast and present medical conditionsCommunication tool for health-care team Plan to provide for continuity of careDocumentation for billing and codingPatient education and researchLegal document admissible in court9-7Importance of Patient Records (cont.)Information included in patient recordName and addressInsurance coverage andperson responsible for paymentOccupationMedical historyCurrent complaintHealth-care needs Medical treatment plan Response to careLab and radiology reports9-8Legal Guidelines for Patient RecordsProof of event or procedure No documentation – no proof that care was doneLegal documentMust document complete information about patient careDocument if patient is noncompliant9-9Standards for RecordsComplete, accurate, and well-documented records are evidence of appropriate careIncomplete, inaccurate, altered, or illegible records may imply a poor standard of careEveryone who documents in the patient record has a responsibility to the patient and employing physician9-10Patient RecordsPatient EducationQuality ofTreatmentResearchAdditional Uses of Patient RecordsTest resultsHealth issuesTreatment instructionsPeer reviewTJC reviewHealth-careanalysis andpolicy decisionsSource of data9-11Apply Your KnowledgeWhat is the purpose of documentation in a patient’s medical record?ANSWER: Documentation in the medical record provides evidence of appropriate care. If a procedure is not documented, it is considered not done.Good Job!9-12Standard Chart InformationPatient Registration Form Date Patient demographic information Age, DOBAddress SSN Insurance/financial information Emergency contact 9-13Standard Chart Information (cont.)Patient medical historyIllnesses, surgeries, allergies, and current medicationsFamily medical historySocial history (diet, exercise, smoking, use of drugs and alcohol)Occupational historyCurrent patient complaint recorded in patient’s own words9-14Standard Chart Information (cont.)Physical examination resultsResults of laboratory and other testsRecords from other physicians or hospitalsInclude a copy of the patient consent authorizing release of information9-15Standard Chart Information (cont.)Doctor’s diagnosis and treatment planTreatment options and final treatment listInstructions to patientMedication prescribedComments or impressionsOperative reports, follow-up visits, and telephone callsThese are part of the continuous patient record Document calls made to and from the patient9-16Standard Chart Information (cont.)Informed consent formsVerify that the patient understands procedures, outcomes, and optionsPatient may withdraw consent at any timeHospital discharge summary formsInformation summarizing the patient’s hospitalizationInstructions for follow-up care Physician signature9-17Correspondence with or about the patientAll written correspondence regarding the patient Record date item was received on the actual formInformation received by fax – request an original copyDate and initial everything you place in the chartStandard Chart Information (cont.)9-18Apply Your KnowledgeWhat section of the patient record contains information about smoking, alcohol use, and occupation?ANSWER: Information about smoking, alcohol use, and occupation is part of the patient’s past medical history.Correct!9-19Initiating and Maintaining Patient RecordsInitial InterviewCompleting medicalhistory formsDocumenting patient statementsDocumenting test resultsExamination, preparation,and vital signsMaintain patient privacy during interview9-20Initiating and Maintaining Patient Records (cont.)Follow-upTranscribe notes the doctor dictatesPost results of laboratory tests and examinations Record all telephone communication with the client Record all medical or discharge instructions given to the client9-21Apply Your KnowledgeIn addition to transcribing notes the doctor dictates and posting lab results, what are two other follow-up tasks the medical assistant might be required to perform as part of follow-up to a patient appointment?ANSWER: The medical assistant may have to record telephone calls with the patient, as well as medical or discharge instructions given to the patient.Right!9-22The Six Cs of ChartingClient’s words –Clarity –Completeness – C onciseness –Chronological order –confidentiality –Do not interpret patient’s wordsCPrecise descriptions/medical terminologyFill out forms completely To the point/approved abbreviationsLegal issuesFollow HIPAA guidelines9-23Apply Your KnowledgeWhat are the six Cs of charting?ANSWER: The six C’s of charting areClient’s words Conciseness Clarity Chronological orderCompleteness ConfidentialityGreat!9-24Types of Medical RecordsSource-Oriented Medical RecordsProblem-Oriented Medical RecordsConventional approachInformation is arranged according to who supplied the dataProblems and treatments are on the same formDifficult to track progress of specific eventsPOMR records make it easier to track specific illnessesInformation included Database Problem list Educational, diagnostic, and treatment plans Progress notes9-25Types of Medical Records (cont.)SOAP documentationOrderly series of steps for dealing with any medical caseLists the followingPatient symptomsDiagnosisSuggested treatmentSOAP9-26Subjective dataObjective dataAssessment PlanInformation the patient tells you What the physician observes during the examinationThe impression of the patient’s problem that leads to diagnosisThe treatment plan to correct the illness or problemSOAP Documentation9-27CHEDDAR FormatExpands on SOAP formatCChief complaint, presenting problems, subjective statementsHHistory: social and physical historyDDetails of problem and complaintsEExaminationDDrugs and dosageAAssessment of diagnostic process and diagnosisRReturn visit information or referral9-28Apply Your KnowledgeLabel the following items as either (S) “subjective” or (O) “objective.”____ headache ____ pulse 72____ vomited x 3 ____ nausea____ skin color ____ respirations 16, labored____ chest pain ____ poor appetiteSOSSSOOO9-29Apply Your KnowledgeWhat type of documentation expands on the SOAP format?ANSWER: CHEDDAR format of documentation.GOOD!9-30Appearance, Timeliness, and Accuracy of RecordsNeatness and legibilityUse a good-quality penBlue ink is preferred (differentiates original from copy)Highlight critical items such as allergiesHandwriting must be legibleMake corrections properly9-31Appearance, Timeliness, and Accuracy of Records (cont.)TimelinessRecord all findings as soon as they are availableFor late entries, record both original date and current dateRecord date and time of telephone calls and information discussedRetrieve file quickly in event of an emergency9-32AccuracyCheck information carefullyNever guess or assume Double-check accuracy findings and instructions Make sure most recent information is recordedAppearance, Timeliness, and Accuracy of Records (cont.)9-33Appearance, Timeliness, and Accuracy of Records (cont.)Professional attitude and toneRecord patient comments in his or her own wordsDo not record your personal or subjective comments, judgments, opinions, or speculationsYou may call attention to problems or observations by attaching a note to the chart, but do not make such comments part of medical record.9-34Electronic Health Records Essential to quality of health care and patient safetyAdvantagesFewer lost recordsReduced transcription costsReadability/legibilityChart access after hoursEasier access to patient education materialsImproved billingDisadvantagesCostlyRetraining of staffIT staff may be neededPossible damage to software and system9-35Electronic Health Records (cont.)Advantages of computer records Can be accessed by more than one person at a timeCan be used in teleconferencesUseful for tickler filesSecurity concerns – protect patient confidentiality9-36Apply Your KnowledgeWhat is important to remember when you are documenting in the medical records?ANSWER: It is important that medical records be neat and legible, timely, accurate, and maintain a professional tone.Very Good!9-37Medical TranscriptionTranscription means transforming spoken words into written formatDictated information is part of the medical record and must be kept confidentialDate and initial each transcription pageStrive for ultimate accuracy and completeness of transcribed information9-38Transcribing direct dictationUse a writing pad and pen that will not smearUse incomplete sentences and phrases to keep up with physician’s paceUse abbreviations accuratelyAsk for clarification immediately if something is unclearRead the dictation back to verify accuracyEnter notes into patient record, date, and initialMedical Transcription (cont.)9-39Transcription AidsTranscriptionreference booksMedicalterminology booksSecretarialbooksMedical referencebooksMedical Transcription (cont.)9-40Apply Your KnowledgeWhen taking direct dictation, when should you clarify information if you do not understand something?ANSWER: You should immediately clarify information that you do not understand when taking direct dictation.Excellent!9-41Correcting and Updating Patient RecordsMedical records are created in “due course”Legal term meaning information is to be entered at the time of occurrenceInformation corrected or added after patient’s visit is regarded as “convenient” Make corrections as soon as possible after the original entry was made9-42Correcting Patient RecordsWhen mistakes happen, correct them immediatelyDraw a line through the original informationIt must remain legibleInsert correct information above or below original line or in marginDocument why correction was madeDate, time, and initial correctionHave a witness, if possibleerorm/d/yyyy 00:00pm misspelled JHCerror/chj9-43Updating Patient RecordsAdditions to record should not appear deceptiveDocument why late entry is madeDate and initial added items May have a third party witness additionAddition made to record because patient called back with additional information.Mm/dd/yyyy – JHC/ chj9-44Apply Your KnowledgeWhat is the appropriate way to correct an error in a patient’s medical record?ANSWER: To correct an error in a patient’s medical record: Draw a line through the original informationIt must remain legible Insert correct information above or below original line or in marginDocument why correction was madeDate, time, and initial correctionSuper Job!9-45Release of RecordsRecords are property of the practiceContain confidential patient health informationMust have patient’s written consent to releaseExceptions: cases of contagious disease or court orderRelease of Informationto HMO Insurance CompanyI authorize Dr. J. Jones to release my health-care information to the above-named insurance company.Christopher Hansen mm/dd/yyyyPatient Signature Date9-46Release of Records (cont.)Procedures for releasing recordsObtain a signed and newly dated release form authorizing the transfer of information, and place it in the patient’s recordMake photocopies of original materialsCopy and send only documents covered in the release authorizationCall to confirm receipt of materials9-47Release of Records (cont.)Special casesDivorce – legal guardian of children (may be one or both parents)Death – next of kin or legally authorized representativeIf unsure, ask supervisorConfidentiality18-year-olds are considered adults in most statesLegal and ethical principle:Protect patient’s right to privacy at all times.9-48Apply Your KnowledgeThe medical assistant receives a fax transmittal authorizing transfer of medical record information for a client to another physician’s office. What would you do in this situation?ANSWER: It is difficult to know the actual originator of a fax transmittal and to verify the signature. The safest solution would be not to release any information based on a fax request and release of information form. Request the original form.Nice Job!9-49In Summary9.1 Patients’ records should be compiled because they serve as legal documents, and may be used in medical malpractice cases and lawsuits.9.2 The content of a patient record consists of standard chart information; information received by fax; dating and initialing of patients’ charts.9-50In Summary (cont.)9.3 To create and maintain patient records formsIncludeRegistration formMedical historyExam results, lab and other testsRecords from other physicians and hospitalsDiagnosis and treatment plansOperative reports, consent forms, discharge summariesCorrespondence with or about patients. Maintain the charts properlyDocumenting detailed notes about the contact with the patient, patient responses and progress, and treatment outcomes.9-51In Summary (cont.)9.4 The most common approaches in documenting information into medical records is through Conventional or Source Oriented records, Problem-Oriented Medical Records (POMR), SOAP, and CHEDDAR.9.5 Neatness, legibility, accuracy, and professional tone are musts in maintaining medical records. 9-52In Summary (cont.)9.6 When performing accurate transcription:Use incomplete sentences or phrases to keep up with the physician’s paceUse abbreviations whenever possibleIf physician speaks fast, ask him or her to speak slower and more clearlyRead dictation back to physician for clarityEnter notes into patient record.9-53In Summary (cont.)9.7 When correcting medical records, make sure you correct as soon as possible. Use appropriate procedure to make corrections.9.8 Each item that is added to the patient record as an update should be dated and initialed. If the information is extremely important, get a third party to witness and initial and date as well.9-54In Summary (cont.)9.9 Medical records can only be released with patient’s written consent or subpoena by the courts. Consent form must be on file.9.10 The advantages of the electronic medical record outweigh the disadvantages. Evaluate software before purchasing. Maintain sensitivity to patient needs.9-55Organization is the power of the day; without it, nothing is accomplished.~ Sophia PalmerFrom A Daybook for Nurses: Making a Difference Each DayEnd of Chapter 9